Provider Demographics
NPI:1790360311
Name:CONTRERAS, MARCOS
Entity Type:Individual
Prefix:
First Name:MARCOS
Middle Name:
Last Name:CONTRERAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 DUNEWOOD DR LOT 70
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-1984
Mailing Address - Country:US
Mailing Address - Phone:815-579-6180
Mailing Address - Fax:
Practice Address - Street 1:1816 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4504
Practice Address - Country:US
Practice Address - Phone:219-874-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN67036628A183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician